Provider Demographics
NPI:1972585131
Name:KELLER, PHILIP E (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:E
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1 WALTER SCHOLER DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-6303
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23984207Q00000X
IN01066617A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI080076573OtherRAILROAD MEDICARE
WI12550OtherDEAN
WI23984OtherTOUCHPOINT
IN200960920Medicaid
WI39080723640OtherUNITY
IN000000631756OtherANTHEM PROVIDER NUMBER
WI30500300Medicaid
WIWI0140OtherJOHN DEERE
WI000316130Medicare ID - Type Unspecified
WI30500300Medicaid
WIWI0140OtherJOHN DEERE
IN200960920Medicaid
IN815500BB6Medicare PIN